Quality versus Safety in Rural Health

The concepts of safety and quality in healthcare have an interesting, and somewhat complex and controversial, relationship. Professor Richard Lilford, Director of the Patient Safety Research Programme at the University of Birmingham, UK, views safety and quality as being at the opposite ends of a causality and immediacy continuum. That is, events for which the causality of the outcome is certain and the outcome occurs shortly after the event (i.e., death immediately following an intrathecal administration of vincristine) are typically perceived as being safety issues, while events for which the causality of the outcome is not certain and the outcome occurs long after the event (i.e., a patient dies from a secondary myocardial infarction years after failing to receive a beta-blocker post myocardial infarction) is typically considered to be a quality issue.1  Others argue that safety is simply the most extreme violation of quality and that safety is freedom from injury, dealing with an additive risk, unlike quality, which deals with reducing existing risks.2

While one would be hard pressed to find someone who felt that neither safety nor quality are important aspects of the healthcare system, there are differing schools of thought about the relative importance of these two concepts. These differences were highlighted in the Annals of Internal Medicine in 2004,2,3 Nonetheless, regardless of one’s perceived relative importance of the concepts of quality and safety, there are some important methodological issues which support the argument of the need for patient safety and quality-specific research, policy and practice.

Quality improvement efforts have important roots in industrial quality management methods based on total quality management and similar initiatives, whereas patient safety draws more from academic disciplines such as human factors engineering and practical strategies used to reduce unintentional incidents in aviation and other used high-risk industries. Patient safety initiatives aim to identify and then prevent or mitigate harm as a result of treatment. Quality improvement initiatives focus on ensuring that all patients receive appropriate care in a timely fashion according to their health care needs.

The figure below expands upon this difference. In general, quality improvement activities work to “raise the ceiling” in healthcare while patient safety activities work to “raise the floor”.

Figure 1. Relationship between quality improvement and patient safety

Relationship between quality improvement and patient safety

Source: Baker et al. In: MacKinnon (2007). Reproduced from Stevens P et al, 2005 (Healthc Q). 

So what about the issue of quality versus safety in the context of rural health? The Institute of Medicine (IOM) report, Quality Through Collaboration: The Future of Rural Health Care, was released in 2004 and touched on this topic. This report reviewed the quality of health care in rural areas and developed a conceptual framework for a core set of services and the essential infrastructure necessary to deliver those services to rural communities.  The IOM committee recommended priority objectives and identified changes in policies and programs to achieve those objectives. The committee also adopted 12 recommendations pertaining to rural health care quality and emphasized the need for the adoption of a national Rural Quality Initiative to assist rural communities and providers in acquiring the knowledge and tools needed to improve quality and safety.  The report also stressed the importance of the applicability of the IOM’s six aims for healthcare to rural America: effective, patient-centered, timely, efficient, equitable and safe. So, according to the IOM, safety is one of six components of a high quality healthcare system.

So, it would seem that both safety and quality are integral to rural health, although the approaches for improving safety and quality may be quite different.

  1. Lilford RJ. Patient safety research. Presentation at Patient Safety Research in Canada: a retreat to identify research priorities. Toronto, ON. Feb 2005.
  2. Woolf SH. Patient safety is not enough: targeting quality improvements to optimize the health of the population. Ann Intern Med 2004;140:33-6.
  3. Wachter RM, Shojania KG. The patient safety movement will help, not harm, quality. Ann Intern Med 2004;141:326-7.
  4. Baker GR, Jeffs L, Law M, Norton PG 2007. Improving the Safety and Quality of Health Care in Canada. In: MacKinnon NJ, ed., Safe and Effective: The Eight Essential Elements of an Optimal Medication-Use System. 2007. Ottawa, ON: Canadian Pharmacists Association.



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